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121 e-Letters

Although it may be difficult to make a distinction between
retropharyngeal abscess, and retropharyngeal cellulitis attributable to
organisms such as Group A bete-haemolytic Streptococcus, Staphylococcus
Aureus, and Group B Streptococcus(1), retropharyngeal abscess should
remain high in the differential diagnosis because Fusobacterium
necrophorum(F necrophorum), the gram negative culprit pathogen,although
initially givin...

Although it may be difficult to make a distinction between
retropharyngeal abscess, and retropharyngeal cellulitis attributable to
organisms such as Group A bete-haemolytic Streptococcus, Staphylococcus
Aureus, and Group B Streptococcus(1), retropharyngeal abscess should
remain high in the differential diagnosis because Fusobacterium
necrophorum(F necrophorum), the gram negative culprit pathogen,although
initially giving rise to pharyngitis(2)or to tonsillitis(3), may
ultimately mandate an antibiotic regime different from the one typically
used for treatment of gram positive infections(4). Among 14 cases of
bacteriologically confirmed F necrophorum infection diagnosed in a
children's hospital, the organism was isolated from peritonsillar abscess
fluid in eight, from blood cultures in five, and from bronchial-alveolar
lavage fluid in one. Lemierre's syndrome(LS) was a complication in four of
these bacteriologically confirmed cases. Of note, among two of the four
bacteriologically validated cases of LS there was serological evidence
suggestive of co-infection with two of the organisms more commonly
associated with tonsillitis. In one instance, the serological evidence
amounted to elevation in Anti Streptolysin O Titre, and, in the other, it
amounted to documentation of a positive Immunoglobulin M titre for Epstein
-Barr Virus(2), the latter generally beleived to be "virtually diagnostic
of primary EBV infection"(5). Accordingly, to paraphrase one commentator,
these cases "draw attention to an alternative pathogen for
tonsillitis"(4), thereby justifying a high index of suspicion for F
necrophorum. In the event that the oragnism cannot be isolated by culture
from appropriate specimens molecular methods, including broad-range 16S
rDNA PCR should be used. The latter startegy has the advantage that it
also encompasses other bacterial infections, such as Group A Streptococci,
Staphylococcus Aureus, and Streptococcus pneumoniae, presenting with
similar clinical features. Furthermore, because the test dtects molecular
material from bacteria, previous antibiotic treatment does not interfere
with the diagnosis(6).
References
(1)Zacharkiwa A., Williams H
A pain in the neck
Arch Dis Child Ed Pract 2013;98:71-72
(2)Ramirez S., Hild TG., Rudolph CN et al
Increased diagnosis of Lemierre Syndrome and other Fusobacterium
necrophorum infections in a children's hospital
Pediatrics 2003;112:e380-e385
(3)Klug TE., Henriksen J-J., Fuursted K., Ovensen T
Significant pathogens in peritonsillar abscess
Eur J Clin Microbiol Infect Dis 2011;30:619-627
(4)Fourage M., Bourguignat C., Fermond B., Delobel P
A recurrent tonsillitis
Lancet 2013;381:266
(5)Luzuriaga K., Sullivan JL
Infectious mononucleosis
N Engl J Med 2010;362:1993-2000
(6)Patel M
16S rDNA PCR in diagnosis of Lemierre's syndrome
Lancet Infectious Diseases 2013;13:197

Conflict of Interest:

.Dear Sir, We read with great interest the accurate paper by Sen et
al. regarding the indications for testing lupus anticoagulants (LA) in
pediatric patients1. We believe that two further considerations might
provide a complete overview on this issue. First, it has to be underlined
the important contribution given by Boffa MC concerning either the
laboratory methods for the detection of LA2 or the association between
an...

.Dear Sir, We read with great interest the accurate paper by Sen et
al. regarding the indications for testing lupus anticoagulants (LA) in
pediatric patients1. We believe that two further considerations might
provide a complete overview on this issue. First, it has to be underlined
the important contribution given by Boffa MC concerning either the
laboratory methods for the detection of LA2 or the association between
antiphospholipid syndrome (APS) and obstetrical complications in women3.
Second, in the article by Sen et al. the authors do not take into
consideration infants born to mothers with APS. To date, it is still
unclear how neonates born to mothers with APS should be evaluated and
which is the true clinical relevance of neonatal antiphospholipid
antibodies (APL). Concerning the indications to LA testing, the authors
suggested two main indications: the presence of thrombosis and/or of
unexplained prolonged aPTT. We agree with the authors concerning the first
indication, i.e. APL testing in all infants with thrombosis even in
neonates born to mothers with negative APL4. Concerning the second
indication, it should be specified that the activated partial
thromboplastin time (aPTT) in neonates is intrinsically longer than in
adults and changes according to postnatal age5. Boffa et al. suggested
that APL should be sistematically tested at birth in neonates born to
mothers with APS6 since unpredictable transplacental passage occurs in
about 30% of cases. The low rate and the unpredictable entity of APL
crossing through the placenta could depend on the absorption of antibodies
by trophoblast cells and by their binding to heparin, administered to
mothers with APS during pregnancy. Interesting data have been recently
provided by the European registry of babies born to mothers with APS7.
First, maternal APL crossing over the placental barrier was confirmed.
Second, the kind of neonatal APL correlated with the same mother's isotype
before 6 months of life and mostly disappeared thereafter. Third, 10% of
children showed persistent APL at 24 months of life. Fourth, de-novo
production of antibodies was reported; in particular, de-novo anti-beta2
glycoprotein-I antibodies synthesis occurred in 16% and LA in 4% of cases.
It was suggested that prolonged APS exposure could represent an
immunological trigger, as well as vaccinations or infections, for de-novo
synthesis of APL. Nevertheless, the exact clinical relevance of neonatal
APL positivity is still poorly understood. Although only few case reports
of thrombosis have been described among children born to mothers with
APS6, this increased prothrombotic risk should not be underestimated. In
addition, the European registry of babies born to mothers with primary APS
reported four cases of neurodevelopmental anomalies during the 5-year
follow-up7. According to the current knowledge on this topic, APL
screening should be performed at birth only in case of thrombosis, and
after 6 months of life in asymptomatic neonates to investigate the
eventual persistence of APL. In this case, a long lasting follow-up is
required to verify the true clinical significance of persisting APL.

Conflict of Interest:

The authors state that INH does not prevent the development of active
tuberculosis. However, it is well known that with lower dosage than
15mg/kg daily of INH, we cannot assure therapeutical INH levels,
precluding its efficacy, as it correlates with lower levels than 3g/l in
the pharmacokinetic parameter of response Cmax

Conflict of Interest:

Straw and Porter write an important article on Sexual health and
Contraception (Arch Dis Chld Educ Pract Ed 2012; 97:177-184), but there
are some points which I think need clarification or correction. There may
also be missed opportunities for highlighting the most effective methods
of contraception in real life situations for young people.
The statement that 'Levonelle 1500 is an an oral progestogen which can be
obtaine...

Straw and Porter write an important article on Sexual health and
Contraception (Arch Dis Chld Educ Pract Ed 2012; 97:177-184), but there
are some points which I think need clarification or correction. There may
also be missed opportunities for highlighting the most effective methods
of contraception in real life situations for young people.
The statement that 'Levonelle 1500 is an an oral progestogen which can be
obtained over the counter at any pharmacy' is misleading. Levonelle 1500
is a Prescription Only Medicine , whereas Levonelle One Step can only be
sold to women over the age of 16. Levonelle 1500 will be issued free in
some pharmacies on a Patient Group Direction where pharmacists have been
trained and approved for its use. The commissioning arrangements for this
are not universal, nor are the upper age limits.

The table of summary of contraceptive methods available for young
people in the UK (Table 1) again has some strange and sometimes out of
date statements. Combined hormonal contraception (pills, patches and
vaginal rings) are no longer consider to become ineffective if non-liver
enzyme inducing antibiotics are taken concurrently or during the 7 days
after cessation 1. The 'progesterone only pill' for which only one brand
name is appended should more correctly be called 'progestogen only pill'
as the hormone is the synthetic form of progesterone. The Today sponge has
not been available in the UK for several years for prescription (it is not
listed in the British National Formulary) but does appear to be available
for direct sale from pharmacies or via the internet. It's failure rate is
not quoted in Table 1 -perhaps because it this appears to be the same as
for spermicide alone, a method which would not be recommended to young
highly fertilie people.

It is a shame that space was not given to emphasising the differing
rates of failure between perfect use of a method when compared to typical
(every day real life) use. Trussell 2 has published updated tables showing
(at the end of 1 year of use in the USA) that user-dependent methods (such
as combined hormonal contraception, POP, and to a lesser degree the
injectable methods) have a much higher failure rates than those quoted in
Table 1 of the article. For this reason, long acting reversible
contraception (such as implants, IUDs and IUS), with additional use of
condoms to decrease transmission of STIs, are encouraged particularly
amongst young women where life styles may make 100% adherence difficult.

Conflict of Interest:

Surprisingly, especially in view of a recent article highlighting the
importance of including a history of recent travel when evaluating
neurological symptoms and signs(1), such an inquiry was not mentioned as a
fundamental requirement in the 15 minute consultation on facial
paralysis(2). In the anecdotal report of a patient with multiple cranial
nerve involvement(inclusing facial nerve paralysis) in whom the diagnosis
of...

Surprisingly, especially in view of a recent article highlighting the
importance of including a history of recent travel when evaluating
neurological symptoms and signs(1), such an inquiry was not mentioned as a
fundamental requirement in the 15 minute consultation on facial
paralysis(2). In the anecdotal report of a patient with multiple cranial
nerve involvement(inclusing facial nerve paralysis) in whom the diagnosis
of neuroborreliosis was initially missed, it was only after an inquiry
abour recent travel was made that the "penny" dropped, and progress was
made towards the correct diagnosis(1). Facial nerve paralysis arguably has
greater relevance in paediatric neuroborreliosis than in adult cases,
having been documented in as many as 71% of chidren with
neuroborreliosis(3). In a review of 66 paediatric cases of central nervous
system infection covering the period January 1, 2004 to December 31, 2006,
in a university hospital in Helsinki, facial nerve paralysis was a
presenting feature in 19 patients with a variety of central nervous system
infections. Thirty two percent of those CNS infections characterised by
facial nerve paralysis were attributable to Lyme disease(4). In the United
Kingdom itself, the true incidence of Lyme disease is unknown but,
according to one view, "it is more common than is thought", as shown by an
audit of a "highly aware" GP parctice in Scotland which found "an
incidence of 370/100,000 population, based on clinical diagnosis of the
erythema migrans rash..."(5). The rash may be on the back of the body and
not seen, or may be present behind the hair line in children, or may have
been forgotten by the time later symptoms develop(5). The latter may have
been the case in the instance of a 12 year old Canadian girl admitted to
hospital with a 10 day history of unilateral facial weakness and
midscapular pain after returning from a holiday in rural France. She did
not recall any insect bites, and the family did not recall a preceding
rash. On examination she had a right sided lower motor neurone facial
nerve palsy, but the unusual additional feature was the coexistence of
spinal cord involvement in a patient of her age(3). Progressive motor
weakness with universal arreflexia is another unusual presenting feature
of neuroborreliosis(6), and this can simulate Guillain- Barre syndrome.
The presence of cerebrospinal fluid(CSF)pleocytosis is one of the
important features which distinguishes this presentation from Guillain-
Barre syndrome(7)(8), given the fact that it is highly exceptional for
Guillain-Barre sysndrome to be characterised by CSF white cell counts(WCC)
of the order of 25-197/microlitre as was the case in 3 patients aged 77,
82, and 82, respectively, who were the subject of one report(9).Lower CSF
white cell counts were documented in the other 2 patients, aged 78 and 82,
who were the subjects of the same report(9).
References
(1) Hobson J., Weatherall MW
A patient's journey. Lyme borreliosis
BMJ 2012;344:46-47
(2) Malik V., Joshi V., Green KMJ., Bruce IA
15 minute consultation: A structured approach to the management of facial
paralysis in a child
Arch Dis Child : Education and Practice 2012;97:82-85
(3)Makhani N., Morris SK., Page AV et al
A twist on Lyme: the challenge of diagnosisng European Lyme
neuroborreliosis
J Clin Microl 2011;49:455-457
(4) Huttunen P., Lappalainen M., Salo E et al
Differential diagnosis of acute central nervous system infections in
children using modern microbiological methods
Acta Paediatrica 2009;98:1300-1306
(5) Pearson S., Huyshe-Shire S
Re: Tick bite and early Lyne borreliosis
BMJ rapid response 25th June 2012
(6) Sterman AB., Nelson S., Barclay P
Demyelinating neuropathy accaompanying Lyme disease
Neurology 1982;32:1302-1305
(7) Hartung H-P., van der Meche FGA., Pollard J
Guillain-Barre syndrome
Current Opinion in Neurology 1998;11:497-513
(8) Burns TEM
Guillain-Barre syndrome
Semin Neurol 2008;28:152-167
(9) Rauschka H., Jellinger K., Lassmann H., Braier F., Schmidbauer M
Guillain-Barre syndrome with marked pleocytosis or a significant
proportion of polymorphonuclear granulocytes in the cerebrospinal fluid:
neuropathological investigation in five cases and review of differential
diagnoses
European Journal of Neurology 2003;10:479-486

Conflict of Interest:

At the heart of good management of the health transition
process(figure 1)(1) should be a recognition of the "power of information-
putting all of us in control of the healthcare information we need"(2).
This can be achieved, in part, through the medium of the so-called
"abbreviated patient-held record"(3), so as to bridge the communication
gap between a variety of healthcare services when the young person makes
the tra...

At the heart of good management of the health transition
process(figure 1)(1) should be a recognition of the "power of information-
putting all of us in control of the healthcare information we need"(2).
This can be achieved, in part, through the medium of the so-called
"abbreviated patient-held record"(3), so as to bridge the communication
gap between a variety of healthcare services when the young person makes
the transition to adult services. In order to optimise the quality and
content of the abbreviated patient-held record its format should, not only
be structured, as recommended for clinic correspondence(4), but also
standardised, so as to include an updated problem list and an updated
drug list(3). The former shuld be mutually agreed between the young person
and the relevant healthcare professional, and the latter should include
prescribed medicines, over the counter medicines, as well as homeopathic
medication.
At each encounter with healthcare professionals, the contents of the
abbreviated health record should be updated, and one copy placed in the
hands of the young person, and one copy transmitted to his general
practitioner.
References
(1) Gleeson H., Turner G
Transition to adult services
Arch Dis Child Educ Pract Ed 2012;97:86-92
(2) The Choice Team, Department of Health, 79 Whitehall, London
A model for shared decision-making
In "Liberating the NHS; No decision about me, without me:Further
consulatation proposals to secure shared decision-making", page 12-13, 23
May 2012
(3) Jolobe OMP
The abbreviated patient-held record: bridging the communication gap
British Journal of Hospital Medicine 1012;73:234
(4) Melville C., Hands S., Jones P
Randomised trial of the effects of structuring clinic correspondence
Arch Dis Child 2001;86:374-5

Conflict of Interest:

In her review of options for procedural pain in newborn infants
Judith Meek is herself premature in her assertion that "the statement that
we are no longer in equipoise over the use of sucrose may be
premature..."[1].

We surveyed current practice and attitudes to procedural pain in
English Neonatal Units in 2011 using paper questionnaires sent to the lead
clinician in each unit. Replies were received from 102 of...

In her review of options for procedural pain in newborn infants
Judith Meek is herself premature in her assertion that "the statement that
we are no longer in equipoise over the use of sucrose may be
premature..."[1].

We surveyed current practice and attitudes to procedural pain in
English Neonatal Units in 2011 using paper questionnaires sent to the lead
clinician in each unit. Replies were received from 102 of 179 units
contacted, of which 29 units had more than 400 admissions/yr, 54 units
had 200-400 admissions/yr and 14 units had less than 200 admissions/yr. 5
units did not report their admission rates.

70 units used sucrose on more than 50% of times for painful
procedures, 10 used sucrose on less than 50% of occasions and 15 did not
use sucrose at all. 72 units agreed that sucrose was safe and effective
at reducing procedural pain. Of the 70 units using sucrose, 60 had a
written guideline for pain relief; such a policy was present in 16 of the
25 units seldom or never using sucrose. Lack of time or demand and
forgetfulness were stated to be the commonest reasons for non-use of
sucrose.

The fact that sucrose is used routinely in at least 73% of units, and
that those units not reporting routine use quoted lack of time or other
operator-dependent factors as being the main reasons for non-use, suggests
that most practitioners are convinced by the considerable scientific
evidence and their own personal experience of the utility of this simple
and safe measure.

We endorse Meek's view of the importance of promoting good nursing
and developmental care; in our study 42 respondents stated that other non-
pharmacological method of pain relief including breast feeding, non-
nutritive sucking, swaddling, cuddling, holding and containment were
useful for reducing procedural pain.

Conflict of Interest:

Respected Sir.
We have read the entire article. We agree with the history and the
condition of the Alice as mentioned by the respected authors. But, we
strongly believe the molecular diagnosis testing must be performed to
confirm Benign hereditary chorea which is map to chromosome 14q (Vries et
al., 1999). Beside mapping a mutation in TITF-1 gene has been reported to
be associated with hereditary benign chorea (Breedveld...

Respected Sir.
We have read the entire article. We agree with the history and the
condition of the Alice as mentioned by the respected authors. But, we
strongly believe the molecular diagnosis testing must be performed to
confirm Benign hereditary chorea which is map to chromosome 14q (Vries et
al., 1999). Beside mapping a mutation in TITF-1 gene has been reported to
be associated with hereditary benign chorea (Breedveld et al., 2002-2).
This mutation in TITF-1 can be analyzed directly but yet considering the
heterogeneity of the benign hereditary chorea, the region 14q13.1-q21.1 at
chromosome could be screened as reported previously (Breedveld et al.,
2002-3).

We agree the differential clinical diagnosis has been performed but
yet it couldn't stand alone in the hereditary disorders in an era of
productivity where a disease could be diagnosed in 1-2 days based on the
molecular findings to have the best of prognosis.

Conflict of Interest:

For the sake of completeness, one should add right-to left shunts to
the list of underlying causes under the heading of "certain populations of
children [who] are at increased risk of IPD(invasive pneumococcal
disease)"(1). Although the most striking example was that of a 77 year old
man(2), the prinicple is also applicable to children with atrial septal
defect(ASD) that this congenital anomaly could predispose to recurren...

For the sake of completeness, one should add right-to left shunts to
the list of underlying causes under the heading of "certain populations of
children [who] are at increased risk of IPD(invasive pneumococcal
disease)"(1). Although the most striking example was that of a 77 year old
man(2), the prinicple is also applicable to children with atrial septal
defect(ASD) that this congenital anomaly could predispose to recurrent
pneumococcal meningitis. In this particular instance three episodes of
pneumococcal meningitis occured over a four year period before the
diagnosis of ASD was considered(2). Recurrent bacterial meningitis may
also be a complication of right- to left shunting attributable to
hereditary haemorrhagic telangiectasia(3), but the bacterial pathogen was
not identified in the review article which cited this complication in
two adults aged 49 qnd 50, repectively(3). Accordingly, even though right-
to left shunts are not considered to be a common predisposing cause for
recurrent pneumococcal meningitis in children, a diligent search should be
made for this risk factor when well recognised underlying causes cannot be
identified, especially in patients who have recurrent episodes of
bacterial meningitis
References
(1) Randle E., Ninis N., Inwald D
Invasive pneumococcal disease
Education and Practice 2011;96:183-190
(2)Spencer SE., D'Cruz IA., Tenholder MF
Recurrent meningitis and severe hypoxemia ina 77 year old man
Chest 1997;112:1120-3
(3)Press OW., Ramsey PG
Cenral nervous system infections associated with hereditary hemorrhagic
telangiectasia
American Journal of Medicine 1984;77:86-92

Conflict of Interest:

We read with great interest the concise and accurate summary of P J
McKiernan regarding best-practice milestones for long-term care following
paediatric liver transplantation (1).

Although we fully agree with all medical considerations raised by the
author, we reckon that the complexity of the psychosocial challenges met
by the patients and their families as they adjust to the process of organ...

We read with great interest the concise and accurate summary of P J
McKiernan regarding best-practice milestones for long-term care following
paediatric liver transplantation (1).

Although we fully agree with all medical considerations raised by the
author, we reckon that the complexity of the psychosocial challenges met
by the patients and their families as they adjust to the process of organ
donation and the chronicity of the condition is underscored. Perceived
quality of life, adherence to medical treatment and successful transition
to self-managed care in adolescent transplant recipients may be seen as
three interrelated indicators of the long-term psychosocial outcome of
transplantation. The unique challenges met by adolescent transplant
recipients include the need to establish a continuous and separate sense
of self while coming to terms with the idea of being a survivor who owes
life to the gift of either a deceased or a living donor.

Our experience suggests that the long-term follow-up of paediatric
liver transplant recipients necessarily requires a special emphasis on
self-management education and preventive psychosocial counseling regarding
the impact of transplantation on family dynamics -even more so if the
donation was living-related. Living-related organ donation is generally
associated with better short and long-term clinical outcomes in recipients
(2). It raises however important ethical issues and there is some emerging
evidence that there might be a risk of long-term adverse psychosocial
consequences on the well-being and autonomous self-management capacity of
adolescent transplant recipients (3,4). As we continue to expand the
limits of our medical possibilities to successfully treat childhood end-
stage liver disease, we need to acknowledge our uncertainty regarding
psychosocial and developmental issues following living-related donation,
and actively engage the resources of our multidisciplinary healthcare
teams to deal with unforeseeable challenges in the long-term follow-up of
our paediatric patients (5).